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WHO suggest new C-section recommendations

Researchers propose that for optimum safety, 19% of births should be by cesarian section, according to research published in JAMA.

Both vaginal and C-section deliveries have risks.

The cesarean section (C-section) is the most commonly performed operation worldwide.

Rates of cesarean delivery vary widely from country to country, ranging from 0.6% in South Sudan to 55.5% in Brazil.

The World Health Organization (WHO) recommend an average of no more than 10-15% of births by C-section, for optimal maternal and neonatal outcomes.

According to the Centers for Disease Control and Prevention (CDC), over 30% of births in the US are by C-section.

Why choose a C-section?

A C-section is normally chosen to make the delivery safer for the mother or child, especially if:

Labor is not progressing, for example if the cervix is not opening or the baby's head is too big to pass through the birth canal

The baby's oxygen supply is at risk

The baby is in an abnormal position, such as breech or transverse

It is a multiple or premature birth

The placenta covers the opening of the cervix (placenta previa)

The umbilical cord is compressed

The mother has complex heart problems, high blood pressure requiring urgent delivery or an infection that could be passed to the baby during vaginal delivery, such as genital herpes or HIV

There is an obstruction, such as a large fibroid, a severely displaced pelvic fracture or if severe hydrocephalus causes the baby's head to be unusually large

A previous C-section puts the mother at risk of complications.

Researchers from Ariadne Labs, of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Massachusetts, and Stanford University School of Medicine in California, gathered and correlated national C-section, maternal and neonatal mortality rates for the year 2012 for all 194 WHO member countries, covering 97.6% of all births worldwide, and accounting for 22.9 million births.

Mathematical modeling was used to predict rates for countries where data was missing and to account for other contributing factors such as health expenditure.

Safest rate may be 19%

This is the first comprehensive analysis of C-section rates for all WHO counties in a year. The 1-year approach avoids the bias caused by using data from varying years, since C-section rates and mortality change over time.

The team found that as the percentage of C-sections increases up to 19%, maternal and neonatal mortality rates decline. Above 19%, no further improvement in maternal and neonatal mortality rates was seen.

Lead investigator Dr. Alex Haynes, a surgeon and associate director of Ariadne Labs' Safe Surgery Program, says that C-sections appear not to be carried out frequently enough in some countries, suggesting inadequate access to safe and timely emergency obstetrical care.

At the same time, he adds, in some countries, they appear more frequent than necessary.

Recovery from a C-section takes longer than does recovery from a vaginal birth, and like all major surgery, there are risks involved.

Babies delivered by C-section have a higher chance of breathing problems. The mother may develop an infection of the incision wound or the lining of the uterus; she may experience increased bleeding, blood clots, injuries to nearby organs, and complications with subsequent births if a vaginal delivery is attempted.

Dr. Haynes suggests that benchmarks for C-section rates on a countrywide level should be reexamined and possibly set higher than previously thought.

Dr. Thomas Weiser, co-author and assistant professor of surgery at Stanford University School of Medicine, says there is a strong argument for improving surgical capacity in countries where access to care is limited, to develop stronger, more resilient health care systems as a whole.

He adds:

"All the things you need to do to build up surgical capacity, like personnel training, improving supply chains, providing clean water and sterile environments, all contribute to general strengthening of health care systems."

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